Bartlett, Margaret NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Mar+:3s1ro.t 11(-)c(itna. 1 art,1 o t L C:ti1110
iiiii Date of Death Age If Veteran of U.S. Armed Forces,
il 9-1 83-2 o 1 1 98 War or Dates NO
ig Place of Death Hospital, Institution or
City, Town or VillagSx1• o W t I- c)r1 Street Address 3 Di mini Ck Road
tii
Manner of Death 0 Natural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
Circumstances Investigation
tri Medical Certifier Name Title
8u.`,,an(10 M. :-i.Jcoi. MO
"iiii j Address
1 'i . Macao c Ori.ve OOt.t 1en.:_,hury, New York 1 2d04
Death Certificate Filed District Number / Register umber
> City, Town or Village '��n• Of W 1 ton st
Date Cemetery or Cremator
':: ❑x Burial `)--2 l-2011 t- ;11 taY.tzarl ;U: ( otmi.
Address
ii ❑Cremation
P 1C1 tl . t t1 efl:bury, New York
Date Place Removed
0❑Removal and/or Held
�- and/or Address
Hold
0 Date Point of
❑Transportation Shipment
3 by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Reinterment Date Cemetery Address
>< Permit Issued to Registration Number
Name of Funeral Home r • :-t• K-I :1 ton r. iA'i1 no cal_ :Joan 0.1 C)"I d
m Address
1 3i) Mi:tin :31 ;oci( (1 (i12mi f+':3.1,I::',, N: w York 12803
ai Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
ILI
it
F<: Permission is Hereby granted to dispose of the human r ains de ribs bone as indicat d.
)..-J(i-- i 1 Registrar4 C/
Date Issued ` of Vital Statistics r � � �, `'�,
(signat e)
District Number Zjili__ Place �o• of Wyi l_t.on, Nt:1w "Y(;C
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:.
F Date of Disposition 9 J /// Place of Disposition •r. %�w.:.r.= U- �c ' -' 1%�: •t 4�-.s�. -i„a�„, ,A'.,/ ";
ii
2 (address) _
ilk , ( ction • . (lot ntArrAber) (grave number)
0 Name of Se lion or Person inChaf e of Premises i _(-;c.--- t`{ rLI.�(;t_:,.i, -i,-�_
g V Rt, 7(: i r (please print)/> Signature C -.- � , -1."-- Title ';i�st, 4 7-
(over)
DOH-1555 (9/98)